Rabbe Takolander

Solitary aneurysms of the iliac arterial system: An estimate of their frequency of occurrence * ** ***

Solitary iliac artery aneurysms are rare, and most reports have been presented as case reports. By combining autopsy records and operating records, a total of 13 cases were found: during a 15-year period (1971 to 1985), 42,010 of the inhabitants of Malmö died (population 230,000) and 35,265 (including 9014 forensic autopsies) underwent autopsy (84%). Solitary iliac artery aneurysms were found in seven (0.03%) of the 26,251 patients who underwent autopsy at the hospital; six of those had been asymptomatic and one was ruptured. Among the 9014 persons who underwent forensic medical autopsy, there were two with ruptured solitary iliac artery aneurysms. Four patients had clinically detected solitary iliac artery aneurysms, three of which were ruptured. All patients underwent surgery, and two of the three patients with ruptured solitary iliac artery aneurysms left the hospital well. The rupture rate of iliac aneurysm among those found at autopsy was one of seven (14%) and among those clinically detected three of four.

Does low-dose acetylsalicylic acid prevent stroke after carotid surgery? A double-blind, placebo-controlled randomized trial.

Background and Purpose The aim of this randomized double-blind, placebo-controlled trial was to evaluate whether neurological deficits could be prevented with low-dose acetylsalicylic acid (ASA) as an adjunct to carotid endarterectomy. Methods A total of 232 patients were randomized to two groups, 75 mg/d ASA starting preoperatively and continued for 6 months (n=117) or placebo (identical tablets) (n=115). The patients were followed up regularly for 1 year. Results The groups were well matched regarding laboratory data and indication for operation. The number of patients with intraoperative or postoperative stroke without complete recovery within 1 week were 0 and 2 at 30 days and 6 months, respectively, in the ASA group, compared with 7 and 11 in the placebo group (P=.01). Including all neurological events within 6 months, this was found in 15 patients in the ASA group compared with 24 in the placebo group (P=.12). Mortality was 0.8% and 3.4% at 30 days and 6 months, respectively, in the ASA group. In the placebo group, the corresponding figures were 4.3% and 6.0%, respectively (P=.12). The intraoperative bleeding did not differ between the groups nor did the number of reoperations due to bleeding or other complications related to pharmacology. Conclusions This study indicates that low-dose ASA (75 mg/d) reduces the number of postoperative strokes without complete recovery within 1 week. Overall neurological events are insignificantly reduced, as also mortality. The use of low-dose ASA (75 mg) seems safe and effective in reducing cerebrovascular events after carotid endarterectomy.

Local Versus General Anaesthesia in Carotid Surgery. A Prospective, Randomised Study

A randomised, prospective study was performed to compare local (LA) and general anaesthesia (GA) in carotid surgery with special emphasis on complications and the need for intra-operative shunting. Fifty-six patients were randomised to LA and 55 to GA. Eight patients in the LA group required a GA for various reasons. During the same period 14 patients were not randomised. Seven perioperative neurological deficits occurred (5.6%), four in the LA group, two in the GA group, and one in the non-randomised group (NS). Selective shunting was used, in the Ga group according to stump pressure or in cases with a previous stroke and in the LA group according to the appearance of neurological symptoms. In the GA group 25 patients were shunted and in the LA group five patients (P less than 0.001) needed a shunt. If strict pressure criteria for shunting had been used in the LA patients, ten would have been shunted and three of the patients who developed symptoms during clamping would not have been shunted. During surgery the highest recorded systolic pressure was significantly higher in the LA group (210 mmHg versus 173 mmHg, P less than 0.001). LA for carotid endarterectomy is comparable with general anaesthesia regarding peroperative complications but produces significantly higher blood pressures than general anaesthesia. On the other hand it allows the possibility of neurologic monitoring of the patient and leads to significantly less use of an intra-operative shunt.

Carotid Artery Surgery. Local versus General Anaesthesia as Related to Sympathetic Activity and Cardiovascular Effects

Arterial plasma catecholamines, blood pressure and heart rate were determined in 75 patients before, during and after carotid endarterectomy. Local anaesthesia given as a cervical block with skin infiltration containing 200 micrograms adrenaline was used in 28 patients (LA-group), general anaesthesia (nitrous oxide, fentanyl, isoflurane) with skin infiltration containing 200 micrograms adrenaline in 32 patients (GAs-group) and general anaesthesia without skin infiltration in 15 patients (GAo-group). In the LA-Group plasma noradrenaline (P-NA) levels were significantly higher during anaesthesia and surgery, with an increase from preanaesthesia levels (P less than 0.05). P-NA decreased from a preanaesthesia level in the GAo-group (P less than 0.01) but remained unaltered in the GAs-group. P-NA values in the GAo-group were lower than those of the GAs-group (P less than 0.001) following anaesthesia and surgery. Plasma adrenaline (P-A) increased in the LA- and the GAs-group and decreased in the GAo-group (P less than 0.001) following anaesthesia and surgery. In the LA-group P-A was similar before the skin incision and clamping but higher after declamping as compared to the GAs-group. Before the skin incision and thereafter P-A was lower in the GAo-group as compared to the other groups. There was a positive correlation between plasma catecholamines, on the one hand, and mean blood pressure and heart rate on the other. Two patients in the LA-, eight in the GAs- and seven in the GAo-group showed a hypotensive blood pressure reaction (SBP less than 100 mmHg; LA vs. GAo, P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Complications after percutaneous transluminal angioplasty in the iliac, femoral, and popliteal arteries.

During a 5-year period percutaneous transluminal angioplasty (PTA) was attempted in 134 iliac, femoral, and popliteal arteries in 127 patients. Complications were systematically registered and classified as major, minor, and radiologic. Seventeen major complications (12.7%), including three deaths, occurred, as well as five minor (3.7%) and 13 radiologic complications (9.7%). The last group showed no clinical symptoms. The frequency of complications in our series is high compared with that found in a survey of 13 studies with 2043 patients. The most marked discrepancy was our high frequency of septic symptoms. A mortality rate of 2.2% was also higher in our series, but we have consequently registered the 30-day mortality rate to make comparisons with surgical series relevant. Radiologic alterations are usually not reported in other series probably because they are regarded as a part of the method, but we consider these alterations as potentially dangerous and important to report because they can result in clinically relevant complications. Because of the complications PTA should only be performed in centers in which complications can be optimally treated.

Late mortality and morbidity after arterial reconstruction: The influence of arteriosclerosis in popliteal artery trifurcation * **

Mortality and the incidence of myocardial infarction and cerebrovascular lesion have been retrospectively analyzed in patients who have survived 30 days after lower limb vascular reconstruction. These events have been related to the extent of arteriosclerotic lesions in the trifurcation of the popliteal artery (trifurcational disease, TFD) in 368 patients treated consecutively. One hundred fifty-five patients underwent aortoiliac reconstruction, 229 had femorodistal bypass, and 16 underwent both procedures. The median follow-up period was 4.4 years. The mortality rate in male and female patients was increased compared with the expected mortality. This increase was found both in patients with and without TFD. In patients having TFD the mortality was 2.0 times higher than in patients who did not have TFD (p less than 0.001). The difference in the mortality rate persisted after correction for the influence of age, sex, and diabetes mellitus. The higher mortality rate in patients who had TFD was most marked early in the postoperative period and was mainly caused by myocardial infarction. The incidence of myocardial infarction and cerebrovascular events was significantly increased in patients who had TFD compared with those who did not, particularly in the early postoperative period.

Analysis of complications after percutaneous transluminal angioplasty of renal artery stenoses

During a five-year-period percutaneous transluminal renal angioplasty (PTRA) was attempted in 90 renal arteries with 109 stenoses and 3 occlusions in 78 patients. Complications were systematically recorded and classified as major, minor and radiological-technical. Twenty-one major complications (20.8%) including one fatality occurred as well as 17 minor, (16.8%) and 37 radiological-technical (36.6%) problems. The last group showed no clinical symptoms. The frequency of complications in our series is high compared with that in a survey of ten papers reviewing results in 675 patients. The most marked discrepancy was our high frequency of septic problems. Radiological changes are not usually reported in other series, probably because they are regarded as methodological but we considered these as potentially dangerous and important to report as they can lead to clinically relevant complications. Because of the problems reported here PTRA should only be performed in centres where complications can be properly dealt with.

Aortic occlusion following blunt trauma of the abdomen

Blunt injuries to the abdominal aorta with initial survival are rare. Two cases of blunt aortic occlusion are reported: one with acute abdominal symptoms and leg ischemia and one with delayed intermittent claudication. The first patient died 9 days postinjury with possible sepsis and bronchopneumonia. The second presented with delayed symptoms 9 years postinjury: fibrous thickening of the intima, a dense, fibrous band around the aorta and left renal vein. After a Dacron graft from the descending thoracic aorta to the external iliac arteries the patient recovered and is employed full time.

The “ad hoc” estimation of outflow does not predict patency of infrainguinal reconstructions*

OBJECTIVES This prospective study was performed to evaluate the clinical implication of the adhoc estimation (also called SVS score) of outflow on patency of infrainguinal in situ femoropopliteal or -distal bypasses. METHODS The bypasses were followed with Duplex scanning at 1, 3, 6, and 12 months after surgery. Fifty-three bypasses were recruited for the study, 20 of which were performed in 17 diabetics. In 47% the adhoc scoring was < or = 4.5 and in 53% it was between 5 and 10 (1 corresponds to an excellent outflow and 10 to a blind segment). RESULTS Within the first 30 days eight occlusions occurred, all of which were surgically corrected. The adhoc score for these bypasses was 4.2 vs. 4.9 (NS) for those who did not occlude. During follow-up, revisions were performed in 21 cases (40%) with 30 interventions. At the end of 1 year, 68% of the bypasses were patent (80% among diabetics and 64% among non-diabetics, NS). Patency at 1 year was not influenced by the adhoc classification. CONCLUSION The estimation of outflow from angiography seems to be of no value in predicting graft patency in infrainguinal grafting.

Pharyngeal function after carotid endarterectomy.

Neurologic deficiencies, with special reference to pharyngeal function, were studied prospectively in 12 patients before and after they underwent carotid endarterectomy. Pharyngeal function was monitored with cineradiography. Five patients developed pharyngeal dysfunction: defective closure of the laryngeal vestibule, epiglottic dysmotility, and pharyngeal constrictor paresis 1 week postoperatively. In 2 patients this dysfunction remained, while in 3 it had resolved 4 weeks after the operation. Pharyngeal dysfunction was more common in patients with preoperative minor stroke and a temporary perioperative carotid shunt and in patients with a long operation time. The registered transient pharyngeal dysfunction may be due to manipulation of the cervical structures including the vagus nerve and the pharynx or due to cerebrovascular damage during the operation. Our findings support careful monitoring of postoperative oral feeding in patients at risk.